Healthcare Provider Details

I. General information

NPI: 1699197574
Provider Name (Legal Business Name): THE PEDIATRIC DENTAL STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 METROPLEX BLVD
PEARL MS
39208-9210
US

IV. Provider business mailing address

603 SOUTHERN OAKS DR
FLORENCE MS
39073-9456
US

V. Phone/Fax

Practice location:
  • Phone: 601-941-6237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3662-12
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3662-12
License Number StateMS

VIII. Authorized Official

Name: DR. JERRICK W ROSE
Title or Position: OWNER
Credential: D.M.D.
Phone: 601-941-6237